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A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Place the client in a private room (Option 1): Given the positive test results for tuberculosis (TB) exposure, placing the client in a private room is crucial for infection control. This helps prevent the spread of TB, which is a highly contagious disease, to other patients and healthcare staff. Isolation is a standard precaution for patients suspected of having active TB.

Apply supplemental oxygen (Option 2): The client's oxygen saturation is low at 88% on room air, indicating hypoxemia. Administering supplemental oxygen is essential to improve the patient's oxygen levels, ensure adequate tissue perfusion, and address any respiratory distress the patient may be experiencing.


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Related Questions

Correct Answer is A

Explanation

A. Calf swelling is a common sign of deep-vein thrombosis (DVT) and should be reported as it could indicate a blood clot, which may lead to serious complications if not addressed.

B. Bradycardia is unrelated to DVT and may be due to other underlying conditions.

C. Clammy skin could indicate shock or other systemic issues but is not directly associated with DVT.

D. Tortuous veins are generally a sign of chronic venous insufficiency, not an acute finding indicative of DVT.

Correct Answer is ["A","D","E","F"]

Explanation

A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.

B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.

C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.

D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.

E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.

F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.

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